ENOT/Ophthalmology Flashcards
(43 cards)
1
Q
sinusitis (acute, subacute, chronic, recurrent) etiology, RF, and sxs
A
- Acute sinusitis: mostly viral, MCC S. pneumo, H flu, M. cat
- cofactor: air pollution, nasal polyps, pregnancy, rhinitis medicamentosa, oral antihypertensives, anti-osteoporosis agents or HRT sprays, mucociliary dysfunction
- sxs: follows URI, up to 4 wk, 2 or more major signs and sxs, 1 major and 2+ minor, nasal purulence on exam, rapid onset
- Major: facial pain, pressure, nasal obstruction, PND, purulence, hyposmia, anosmia, fever
- Minor: HA, halitosis, fatigue, dental pain, cough, ear pain, pressure, fullness
- signs: TTP over affected sinus
- Subacute sxs: same as acute, but complications include orbital cellulitis, osteomyelitis, cavernous sinus thrombosis
- chronic: MCC = S. aureus, sxs are same as acute but 12+ wks
- Recurrent sxs: 4+ eps of acute dz per year, lasting 7+ d
2
Q
sinusitus (acute, subacute, chronic, recurrent) dx and tx
A
- dx: clinical dx - routine radiographs not recommended, nasal endoscopy for pts who dont respond to tx, CT >>> MRI
- tx: supportive - NSAIDs, hydration, nasal saline sprays, steam, mucolytic (guaifenesin like mucinex, robitussin)
- oral decongestant: sudafed, topical nasal casoconstrictors (phenylephrine or afrin), intranasal steroids
- oral abx x 1-2wk: amox (1st line), augmentin, macrolide or bactrim if PCN allergy, FQ, 3rd gen ceph.
- consider bact if sxs worsen after 5d, persist 10+d, or out of proportion to viral infxn
3
Q
Meniere disease
A
- endolymphatic hydrops
- excessive endolymph in cochlea overstim hairs causing vertigo and sudden hearing loss with aural fullness, unknown etiology
- sxs: sudden, recurrent vertigo (minutes to hrs), lower range hearing loss, tinnitus, one sided aural pain/pressure/fullness, N/V
- signs: nystagmus on impaired side
- dx: audiometry, caloric testing
- tx: low sodium/high H2O diet, diuretics (acetazolamide), intratympanic gentamicin, referral to ENT
- avoid ETOH, caffeine, tobacco
4
Q
labrynthitis
A
- unkown etiology, likely viral, head injury, stress or allergy related
- sxs: acute severe vertigo, lasting several days to a week, improves over a few weeks, but hearing loss may or may not resolve, imbalance, hearing loss, nausea or vomiting
- signs: severe nystagmus
- tx: abx for fever or signs of infxn, vestibular suppressants for acute sxs (diasepam, meclizine), sxs regress after 3-6wk
5
Q
tinnitus
A
- sxs: ringing in the ears
- dx: comprehensive audiologic examination for unilateral persistent tinnitus or associated hearing impairment, imaging for unilateral tinnitus, pulsatile tinnitus, asymmetric hearing loss, or focal neuro deficits
- tx: hearing aids for tinnitus with hearing loss, CBT or sound tx for persistent, bothersome tinnitus
6
Q
Tympanic membrane perforation (barotrauma/TM perforation)
A
- MCC: infxn (AOM), trauma (barotrauma, direct impact, explosion)
- sxs: most are asxatic, audible whistling sounds during blowing nose and sneezing, decreased hearing, increased tendency of ear infxn during colds and with water immersion
- signs: copious sanguineous purulent d/c, painless if no overlying infxn or cholesteatoma
- dx: clinical dx, tympanometry
- tx: most self-resolve and asx not requiring tx, no tx for nonswimming pts w/ minimal hearing loss, systemic abx (bactrim, amox), trichloroacetic acid to cauterize edges of TMP, surg repair of TM
- avoid water exposure, avoid eardrops containing gentamicin, neomicin sulfate, tobramycin
7
Q
otitis externa - bacterial
A
- “swimmers ear”; MCC = pseudomonas, proteus, fungi
- RF: water, trauma, exfoliative skin conditions (psoriasis, eczema)
- sxs: ear pain (especially w/ mvmt of auricle, tragus, or eating)
- signs: redness, swelling of ear canal or purulent exudate, foul smelling, pre- or postauricular LAD
- dx: tuning fork BC > AC
- tx: abx drops - aminoglyc (neomycin, polymyxin), FQ (ofloxacin), +/- topical steroid
- complications: in DM or immunocomp - malignant otitis ex may develop (needs hosp and IV abx), periauricular cellulitis, cranial nerve palsies
8
Q
otitis externa - fungal (mycotic otitis externa)
A
- MCC: aspergillus niger (black), A. flavus (yellow), or A. fumigatus (gray), candida albicans (white)
- sxs: pruritis, weeping, pain, hearing loss, aural fullness
- signs: swollen, hyphae +/- spores, moist/wet
- tx: hygiene, topical antifungal powder + antifungal otic drops (acetic acid, vosol)
- prophylaxis: 1:1 ethanol/white vinegar in each ear after showering
9
Q
acute otitis media
A
- viral URI - eustachian tube dysfn or blockage, buildup of fluid/mucus, anatomic deformities or edema
- in infants and children - S. pneumo, H flu, M. cat, S. pyogenes; adults - mostly viral
- sxs: fever, otalgia, ear pressure/fullness, hearing loss
- otoscopic exam: TM erythema, pneumotoscopy, bulging, pre or postauricular LAD
- dx: tuning fork (BC > AC), tympanometry
- tx: watch and wait for older kids, HD amox (1st line), ceftriaxone, resistant = cefaclor or augmentin, recurrent = tympanostomy, tympanocentesis, myringotomy
- complications: mastoiditis, Bell’s palsy, central venous sinus thrombosis, hearing loss, speech delay, bact meningitis, intracranial abscess, TM perf
10
Q
chronic otitis media
A
- repeated eps of AOM, trauma or cholesteatoma
- MCC: S aureus, pseudomonas, proteus, anaerobes
- sxs: TM perf and chronic clear dc w/ or w/out pain, TM and/or ossicular damage leads to hearing loss
- tx: removal of infxed debris, avoid H2O, topical abx drops (cipro and dex = CIPRODEX), surgery is definitive (TM repair or reconstruction), tympanostomy tubes for COM and complications, recurrent AOM, and abx failure in kids
11
Q
serous OM
A
- effusion without infxn, retention of transudate fluid in middle ear
- hx: recent viral URTI, sinus infxn, allergies, flying while congested, AOM, adenoid hypertrophy, nasopharyngeal mass
- sxs: fullness, pressure, hearing loss, popping/gurgling after yawn or blowing nose, dizziness or swimming sensation
- signs: retracted TM, amber-or coca cola colored fluid, displaced cone of light, air bubbles behind TM
- dx: pneumatic otoscopy (dec mvmt TM), BC >AC
- tx: resolves slowly, nasal steroid sprays, short course PO roids, consider tympanostomy after 3mo
- **avoid decongestants, antihistamines, abx
12
Q
Cholesteatoma
A
- chornic neg pressure thins TM and retracts, adhering TM to middle ear → squamous ep forms inside and expands
- sxs: hx of AOM or previous surg - worsening hearing loss, chronic dc, fullness, not painful
- signs: pearly white mass, squamous debris, dc, conductive hearing loss
- dx: weber (lat to affected ear), rinne test (bone >air conduction on affected side)
13
Q
blepharitis
A
- chronic conjunctival and lid margin inflamm
- causes: seborrhea, staph or strep, dysfn of meibomian glands
- post more common, inflamm of inner eyelid at level of meib gland
- sxs: rims red, eyelashes adhere, dandruff like deposits, clear to red conjunctiva, thick, cloudy discharge, gritty or burning, excessive tearing, itchy eyelids, photophobia
- signs: greasy appearance of lid margin w/ scaling around lashes
- dx: slit lamp
- tx: warm compress, lid massage, lid washing, topic abx if infxn (azithro), oral abx (azithro, doxy, tetra)
- associated probs: rosacea, seb derm
14
Q
Bacterial conjunctivitis
A
- associated: steroid or OTC eye drops, contact lens, age, sexual activity, immunodef.
- MCC: S. pneumo, S. aureus, H. aegyptius, M. cat
- transmission: direct contact or fomites (autoinnoc)
- rare: chlamydia or gonorrhea
- direct contact, fomites, nonchlorinated swimming pool, sexual contact, SVD
- sxs: injection, purulent dc, difficulty prying lid open upon awakening
- signs: no preauric LAD, yellow-green dc, bilateral injection
- tx: self-limiting but secondary keratitis may dev., topical sulfonamide (TMP-SMX), gentamicin, tobramicin, norfloxacin, or TMP-polymyxin B sulfate, good handwashing, avoid contaminated pillows/makeup, etc
15
Q
viral conjunctivitis
A
- MC = adenovirus, midsummer to early fall
- highly contagious
- transmission: direct contact, swimming pools
- sxs: recent URTI, no resolution w/ eye drops, unilateral or bilateral, ipsilateral preauricular lymphadenopathy, epiphora (watery dc)
- signs: hyperemia, chemosis, follicular conjunctival injection, subconjunct. hemorrhage
- tx: eye lavage w/ nl saline, vasoconstrictor anthistamine drops, opthalmic sulfonamide drops, supportive (cold, lubricants, hand hygiene)
- prognosis: self-limiting 2-4wks
16
Q
hordeolum
A
- acute development of small, painful nodule or pustule on upper or lower eyelid
- MCC: s aureus, not contagious
- inflamm of meibomian gland with pustular formation, deep
- glands of Zeis (external, stye) infection at eyelid margin, points out
- sxs: acute, edema, palpable induration w/ central purulence and erythema
- tx: spontaneously resolves, warm compress, topical abx for 2ary infxn, IandD if no resolution
17
Q
dacrocystitis
A
- inflamm of lacrimal gland caused by obst.
- Acute: s. aureus and B-hemolytic strep, s. epidermidis, candida
- Chronic: candida, anaeropic strep, s. epidermidis
- sxs: painful erythema over tear duct at nasal side of eye (swelling, TTP), tearing or purulent drainage
- tx: hot compress, abx, if abscess forms →I and D required, if recurrent → dacryocystorhinostomy or dacryocystectomy
18
Q
ectropion
A
outward turning of eyelid
19
Q
entropion
A
inward turning of eyelid
20
Q
corneal abrasion
A
- MCC: contact lenses; other causes: fingernail, eyelash, small FB
- sxs: pain, FB sensation, photophobia, tearing, injection, blepharospasm, blurred vision
- signs: multiple vertical linear abrasions under upper eyelid suggests FB, record visual acuity before exam
- dx: slit lamp or fluorescein stain
- tx: topical anesthetic, saline irrigation, abx ointment (gent, sulfacetamide), tylenol for pain, patchin no longer than 24h, daily FU and referral
21
Q
corneal ulcer
A
- MCC: pseudomonas, staph, strep, HSV, acanthamoeba
- etiology: contact lenses, trauma, poor lid apposition
- sxs: pain, photophobia, dc, tearing, decreased vision, FB sensation
- signs: circumcorneal injection, watery to purulent dc
- dx: stains and cultures ASAP, slit lamp, dendritic lesion = herpes keratitis
- tx: immediate ophthalmology consult, intensive topical abx (FQ, ceph or vanco +/- aminoglyc), STEROIDS AND PATCHING CONTRAINDICATED (dc contact lenses, discard opened lens and solutions, sterilize lens equipment)
22
Q
glaucoma
A
- increased IOP with optic nerve damage
- dx: visual field testing, opthalmoscopy, gonioscopy (determines cause), tonometry to measure IOP
- Normal IOP: 10-21 mmHg
23
Q
acute angle closure glaucoma
A
- peripheral iris blocks outflow of aqueous humor from anterior chamber, associated with papillary dilation
- RF: old, asian, hyperopes
- sxs: sudden dull or severe eye pain (bilateral), worse in dark rooms, blurry vision, frontal HA, tearing, N/V, sweating
- PE: conjunctival hyperemia, ciliary flush, cloudy or hazy cornea, midposition or middilated and nonreactive pupil
- dx: penlight test - project from lateral to nasal, will project shadow on nasal side; tonometry (markedly increased IOP), cornea edematous
- tx: immediate referral, first line topical agents = BB, alpha antag (brimonidine, apraclonidine0, prostaglandin analogues (latanoprost)
- topical miotic: pilocarpine
- adjunct cycloplegic agents: IV acetazolamide, IV mannitol
- laser iridotomy (definitive)
- DO NOT administer mydriatics to these pts
24
Q
Chronic (primary open angle) glaucoma
A
- more common than acute
- RF: >40yo, AA, FHx of glaucoma or diabetes
- MCC: outflow obstruction through trabecular meshwork
- sxs: gradual loss of periph vision, PAINLESS
- dx: increased IOP, defects in periph visual field, increased cup-to-disc ratio
- tx: refer immediately, topical meds (BB, alpha agonist, carbonica anhydrase inhib) to decrease production, prostaglandin analogue, cholinergics, or epi to increase outflow, laser or surgical tx
25
hyphema
* blood in the anterior chamber resulting from a rupture of one or more iris stromal vessels, MC in children (70%)
* RF: sickle cell dz or trait, AA, ASA use
* tx: rest, elevation of head, topical steroids, avoid ASA and NSAIDs
* Complications: 4 S's - Staining of cornea, Synechiae (iris adheres to cornea or lens), Secondary rebleed on days 2-5, Significantly increased IOP
* Prognosis: poor prognostic factors = hyphema in greater 1/3 of anterior chamber, tx after 24h, high IOP, prior low visual acuity
26
papilledema
* bilateral edema of head of optic nerve dt increased ICP → disc margins blurred, cup diminished or gone, nerve head elevated w/ vasc congestion, flame-shaped hemorrhages seen on or adjacent to nerve head
* causes: **malignant HTN,** hemorrhagic stoke, acute subdural hematoma, pseudotumor cerebri
* sxs: asx or transient visual alterations (seconds), **bilateral**, develops over hours to weeks
* dx: disc appears swollen, ICP increased
* tx: tx underlying cause
27
pterygium
* "surfer's eye", commonly grows from nasal side of conjunctiva, small raised nodule at temporal or nasal limbus
* sxs: slowly growing thickening of bulbar conjunctiva, unilateral or bilateral, interferes with vision if reaches cornea
* tx: excision, recurrence is commone, may be more aggressive
28
retinopathy
* systemic disorders including DM, HTN, preeclamp/eclamp, blood dyscrasia, and HIV
* Prolonged **hyperglyc** causes basement membrane thickening, decreased pericytes, microaneurysms, neovasc; **leading cause of blindness in adults**
* tx: if diabetic, get yearly ophthal exams, optimize glucose control, regulate BP, laser photocoag, vitrectomy
* diabetic proliferative retinopathy: **neovascularization** breaks through inner limiting membrane leading to tractional retinal detachment, **vitreous hemorrhage**
* nonproliferative retinopathy: microaneurysms, hard exudates, retinal hemorrhages, venous dilation
29
retinal detachment
* separation of retina from pigmented ep layer, can occur spontaneously or 2ary to trauma or extreme myopia
* sxs: **curtain of darkness** with periph flashes, preceding post vitreous detachment (**flashes of light, floaters,** feeling of heaviness in eye, **acute onset, painless vision loss** (peripheral to central loss), blurred or blackened vision over several hours, partial or complete monocular blindness
* dx: detached retinal flapping in vitreous humor
* tx: **emergent ophthal consult**, remain supine w/ head turned to side of detachment, laser surg or cryosurg
* Prognosis: 80% recover w/ no recurrenc, 15% require retreatment, 5% will never reattach
30
Central . retinal artery occlusion
* **Cherry red spot, ischemic retina**
* flow through CRA occluded, **atherosclerotic** thrombosis, embolus, giant cell arteritis
* sxs: **sudden painless unilateral vision loss**
* PE: **pale grey retina,** cherry dot
* dx: fundoscopy - arteriolar narrowing, separation of arterial flow, retinal edema, perifoveal atrphy (cherry red spot), ganglionic death leads to optic atrophy and pale retina
* tx: **emergent ophthal consult** (dec IOP, arterial dilation, paracentesis), workup and management of atherosclerotic dz, **irreversible damage to retina after 90mins (poor prog)**
31
central retinal vein occlusion
* **blood and thunder fundus**
* 50+, MC associated with HTN, POAG, occurs secondary to **thrombotic event**
* sxs: **sudden, painless unilateral vision loss,** blurred or complete loss
* PE: retinal hemorrhages in all quadrants
* dx: fundoscopy - dilated veins, macular edema, cotton wool spot, massive superficial/deep hemorrhage with vitreous involvement
* tx: spontaneously resolves over time, workup for thrombosis
32
macular degeneration
* RF: long hx of **smoking**, metabolic syndrome, FHx, F, white, **\>50yo**, drugs (chloroquine, phenothiazine), **leading cause of irreversible central vision loss**
* sxs: insidious onset, **gradual loss of central vision clarity** (metamorphopsia - wavy or distorted vision, measure with Amsler grid)
* dx: **drusen formation**, mottling, serous leaks, hemorrhages on retina
* tx: no effective tx, laser tx, **anti VEGF intravitreal injecitons** of monoclonal antibody drugs: slows progression, vitamins and antioxidants slow progression
33
allergic rhinitis
* IgE-mediated reactivity to airborne Ags (pollen, molds, danders, dust)
* RF: FHx, atopic triad (asthma, eczema, allergic rhinitis)
* sxs: similar to common cold, allergic shiners, rhinorrhea, itchy watery eyes, sneezing, nasal congestion, dry cough
* signs: pale, boggy, bluish mucosa, clear, watey dc
* dx: clinical dx
* tx: avoid known allergens and use antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, immunotx
34
anterior epistaxis
* **kiesselbach plexus**
* RF: nose picking, dry nasal mucosa, HTN, cocaine, ETOH, more than 90% of bleeds
* sxs: typically unilateral and easily visualized
* dx: clinical dx
* tx: **direct pressure** at site of bleed (sit, leaning forward, compress nares 15min)
* topical cocaine used as anesthetic and vasoconstrictor, or other topical decongestatnts (oxymetazoline) and anesthetics (lidocaine)
35
posterior epistaxis
* posterior is less common occuring in Woodruff plexus
* RF: HTN, atherosclerosis
* sxs: typically bilateral or from posterior pharynx, if placement of ant pack doesnt stop bleeding and bleeding noted in post pharynx
* dx: clinical dx
* tx: posterior packing is difficult and high risk of complications, consult with inpt monitoring (balloon packing)
* prognosis: greater risk of airway compromise, aspiration of blood, and more difficult to control bleeding
36
nasal polyps
* associated: allergic rhinitis, hx of nasal polyps and asthma
* sxs: pale, boggy masses on the nasal mucosa, chronic congestion, decreased sense of smell
* tx: 3 mo course topical nasal corticosteroid (first line) for small polyps, oral steroids with 6d taper to reduce size, surgical removal
* Note: ASA contrainidicated, possibility of severe bronchospasm
37
strep pharyngitis and tonsilitis and exudative pharyngitis
* Group A B-hemolytic Strep - treat to prevent complications
* viral \>\>\> bacterial
* sxs: **rapid onset high fever, sore throat, lack of cough** (not suggestive of strep = coryza, hoarseness, cough)
* signs: beefy-red uvula, tender anterior cervical adenopathy, palatal petechiae, gray furry tongue, **pharyngotonsillar exudate**
* **CENTOR CRITERIA:** presents of 1-4 suggests GABHS
* dx: if 3/4 criteria met → **rapid strep test,** if neg → throat cx (confirms, GOLD STANDARD)
* tx: **IM PCN**, oral PCN, if PCN allergy give macrolide (erythromycin)
* complications: scarlet fever, glomerulonephritis, abscess formation
38
peritonsillar abscess
* penetration of infxn through tonsillar capsule
* sxs: sore throat, pain with swallowing (odynophagia), trismus, deviation of soft palate or uvula, **muffled "hot potato" voice**
* signs: deviation of soft palate, asymmetric risk of uvula, erythematous and edematous tonsil
* dx: neck CT
tx: **needle aspiration,** incision and drainage +/- abx (IV amox, unasyn, and clinda), tonsillectomy
39
aphthous ulcers
* canker sores, ulcerative stomatitis
* unclear etiology, may be associated with HHV-6
* sxs: single or multiple painful, round ulcers with yellow-gray centers and red halos, occur on nonkeratinized mucosa, usually recurrent
* tx: OTC topical anesthetics, nonspecific topical tx (**steroids)** provide sx relief, 1 wk oral prednisone taper, cimetidine (maintenance) in recurrent cases
40
laryngitis
* **viral \>\>\> bacterial** (M. cat, H. flu)
* follows URI: hoarseness, cough, absence of pain or sore throat
* tx: supportive care (vocal rest, avoidance of singing, shouting), if bacterial → erythromycin, cefuroxime or agumentin, oral or IM steroids for faster recovery but requires vocal fold eval
* complications: vocal fold hemorrhage, polyp or cyst formation
41
Mumps parotitis
* Develops in 70-90% sxatic infxns w/in 24hrs of prodromal sx onset but can begin as long as a week after
* First most common complication/manifestation of mumps
* MCC: **paramyxovirus,** but also caused by influenza, parainfluenza, coxsackie, echovirus, HIV
* MC: children \<15
* transmission: airborne droplets
* sxs: lo fever, malaise, myalgia, arthralgias, HA, anorexia, acute onset unilat or **bilat swelling of parotid or salivary glands** lasting \>2d, tenderness and obliteration of space between earlobe and angle of mandible, earache and difficulty swallowing, eating, or talking
* signs: gland is tense, painful, erythema and warmth absent, no pus expressed from stensen duct
* dx: clinical, CT
* tx: supportive (self-limiting)
* children shouldnt return to school for 9 days after onset of swelling
42
suppurative parotitis
* newborns and debilitated elderly, bact infxn of parotic gland in pts w/ compromised salivary flow, caused by retrograde flow of oral bacteria into salivary ducts and parenchyma
* MCC: S. aureus
* RF: recent anesthesia, dehydration, prematurity, advanced age, sialolithiasis, oral CA, salivary druct strictures, tracheostomy, ductal foreign bodies; medications; chronic illness
* sxs: rapid onset swollen parotid gland, TTP and erythema, usually unilateral, drainage of purulent material from Stenson duct, fever
* signs: gland is tense and painful, erythema and warmth, pus, fever, trismus
* dx: clinical, culture dc, CBC (leukocytosis)
* tx: hydration w/ fluids, massage, stimulate salivation, dc drugs that cause dry mouth, PO abx (augmentin, clinda, cephalexin w/ flagyl), IV abx (nafcillin, unasyn, vanco + flagyl), neonates = gent + antistaphylococcal abx
43
sialadenitis
* affects parotid or submandib gland, occurs w/ dehydration of chronic illness (Sjogren syndrome0, ductal obst.
* MC bug: S. aureus
* sxs: acute swelling of gland, increased pain and swelling with eating, TTP, erythema, pus
* dx: US or CT to dx
* tx: IV abx (nafcillin), hydration, warm compress, sialagogues, massage gland, oral abx, resolves 2-3wks
* complications: abscess, ductal stricture, stone, tumor
